NASPCB Volunteer Application (CCSD Exam) Thank you for your interest in volunteering as a Subject Matter Expert (SME) for the Certified Construction Safety Director (CCSD) Certification Exam Development and Maintenance! Completion of this application is for interest in the below services needed throughout the year by the NASP/IASP, Inc. Certification Program and the NASPCB. We look forward to your help in promoting workplace safety!Please check which of the following you are interested in:(Required) NASPCB Board of Advisors Knowledge and Skills Committee Item Writing Committee Examination Committee Appeals/Complaints Committee Name(Required) First Middle Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Preferred Phone(Required)Work PhoneCell PhoneHome PhoneEmail(Required) Demographic Information This section is NOT optional. Volunteers completing this form must hold a High School Diploma or GED. This section is used to gather the demographic make-up of our volunteers.Date of Birth(Required) MM slash DD slash YYYY Age(Required)Please enter a number from 18 to 100.Gender(Required) Male Female Other Prefer not to answer Education(Required) High School or GED Some college credits, no degree Associate degree Bachelor's degree Master's degree Doctorate Special Skills / Additional InformationCurrent Job Title(Required)Current Company(Required)Years of Experience in Safety (Minimum requirements are 6 years of construction safety experience, and at least 50% of the current role is in construction safety)(Required)Please enter a number from 0 to 100.Company Industry(Required)Agriculture/Forestry/Fishing/HuntingMining/Quarrying/Oil/GasUtilitiesConstructionManufacturingWholesale TradeRetail TradeTransportation/WarehousingInformationFinance/InsuranceReal Estate/Renting/LeasingProfessional/Scientific/Testing ServicesManagementWaste Management/RemediationEducationalHealth Care/Social ServicesArts/Entertainment/RecreationAccommodations/Food ServicePublic AdministrationPrimary Safety Specialty(Required)Occupational SafetyConstruction SafetyGeneral SafetyProcess SafetyProduct SafetySystem SafetyTransportation SafetyFire ProtectionIndustrial HygieneEnvironmentalCurrent Credentials Held - Must hold CSMC(Required) Certified Safety Manager Construction (CSMC) certificate - NASP Do you hold any of the following credentials? Construction Health and Safety Technician (CHST) - BCSP Safety Trained Supervisor Construction (STSC) - BCSP Certified Safety Professional (CSP) - BCSP Associate Safety Professional (ASP) - BCSP Certified Construction Manager (CCM) – CMCI Certified Associate Constructor (CAC) – AIC Certified Professional Constructor (CPC) – AIC OSHA 500 Trainer Construction Master Safety Professional (MSP) Credential - NASP Certified Safety Director (CSD) Credential - NASP Please list other construction-related credentials heldAre you a Veteran?(Required) Yes No Background Disclosure NASPCB may obtain arrest and conviction records and reported unethical behavior on all potential volunteers. An arrest or conviction will not automatically eliminate you from consideration for volunteering. However, failure to list all pending charges and/or convictions may lead to your disqualification or termination of volunteering with NASPCB. Examples may include, but are not limited to: driving while impaired, worthless checks, assault, driving while license is suspended, disorderly conduct, credit card fraud, embezzlement, etc.Have you ever been convicted of any criminal violation of law, or are you now subject to a pending investigation of charges for violation of criminal law?(Required) Yes No Have you been convicted of a misdemeanor within the last five (5) years?(Required) Yes No Do you have a record of any unethical behavior?(Required) Yes No Have you ever had a professional registration, license, or certification denied, suspended, or revoked other than for lack of minimum qualifications, failure of examination, or failure to pay renewal fees?(Required) Yes No Confidentiality Confidentiality: If accepted as a volunteer, I understand I will be required to sign and uphold the NASPCB Code of Ethics, Non-Disclosure, and Conflict of Interest Agreements. To see the NASPCB Code of Ethics, Conflict of Interest, and Non-Disclosure Agreements, Click here. Volunteer Agreement As a volunteer, I understand and agree: My services are donated to NASPCB without contemplation of compensation or future employment. Opportunities for volunteers are provided without regard to religion, creed, race, national origin, age, gender, or sexual orientation. Completing a volunteer application does not guarantee placement, given the number of applicants may exceed the number of available openings and must be approved by the NASPCB Board of Advisors. The information provided is accurate, and verification shall be provided upon request. By checking 'I agree' this serves as your agreement and attestation of the statements in this volunteer agreement. I agree(Required) Yes No Name(Required) First Last Signature(Required)Date(Required) MM slash DD slash YYYY Time(Required) Hours : Minutes AM PM AM/PM
